2015-18 patient safety plan - brockville general hospital · patient safety education program...

Last updated on February 3, 2015

2015-18 Patient Safety Plan

P a g e | 2

Contents Introduction ........................................................................................................................ 3

Guiding Principles ............................................................................................................... 3

Overview ............................................................................................................................. 3

Scope of the Program ......................................................................................................... 4

Key Outcomes ..................................................................................................................... 5

Responsibility ...................................................................................................................... 5

Steps .................................................................................................................................... 6

Additional Programs being Monitored and Evaluated ..................................................... 14

P a g e | 3

Introduction

The Brockville General Hospital has established a strong commitment to Patient Safety and Quality. Our Patient Safety program is designed to align with and support our mission, vision, and values.

The Brockville General Hospital has adopted Accreditation Canada’s Required Organizational Practices (ROPs) and the CPSI safety compliances as key drivers for Patient Safety in the organization. Appropriate policies and procedures have been developed, implemented and evaluated to meet these requirements. The primary focus of this plan is to prevent harm, and promote the safety of all patients, visitors, volunteers, physicians, and staff.

Guiding Principles

We are a learning organization, striving to add value to our care and to

understand how best to work with complexity to be most resilient.

We aspire to the safest patient care, enabled by our Board and Senior

Leadership.

Safety leadership is the responsibility of all Board members, staff, physicians,

volunteers, patients, and visitors.

Patient safety is not a stand-alone program. Accountability is rooted in clinical

practice and policy, how we prevent and manage adverse events for the purpose

of learning and mitigating future risk, and continually improving care and service.

The organization promotes a safe culture, with the goal of developing an

environment that is built on trust and just care for all.

Safe patient care is fostered through a safe and secure work environment for

staff, volunteers and physicians. We will constantly pursue unsafe care

conditions.

Overview The Brockville General Hospital promotes an organizational safety culture that:

P a g e | 4

Encourages recognition, reporting, and acknowledgement of risks/errors to

patient/visitor and employee safety

Initiates/monitors actions to reduce these risks/errors

Promotes a non-punitive environment for reporting and follow-up of safety

incidents

Supports staff who have been involved in a medical/healthcare incident

Educates staff to ensure participation in the program

Ensures that all patients/families are informed about the results of care,

including unexpected outcomes and safety incidents.

Ensures that patients/families are aware of safety practices and expectations

and feel encouraged to ask for clarification of process or procedure.

Scope of the Program 1. Quality Indicators of Patient Safety

Unusual Occurrence Reporting (Medication Safety, Falls)

Medication Reconciliation at Care Transitions

Nosocomial Infections

Surgical site infections

Surgical Safety Checklist

Pressure Ulcers

Transfusion reactions/blood/blood product administration

Use of Restraints

Employee Safety

Venous Thromboembolic Prophylaxis (VTE)

2. Safety Programs

Immunization Programs

MoreOB Program

Emergency Preparedness

Infection Control Program (including Hand Hygiene)

Antimicrobial Stewardship Program

Accreditation

Patient Wellness Programs (e.g. GSS Walking Group, Tai Chi, Lunch

Bunch)

Preventative Maintenance Program

3. Data from Environmental Safety Issues such as:

Product Recalls

Drug Recalls

P a g e | 5

Product/equipment malfunction

Air Quality

Disaster planning

Security incidents

Workplace Violence

4. Data from external sources such as:

Health Quality Ontario (HQO)

Canadian Institute for Health Information (CIHI)

Institute for Safe Medication Practices (ISMP)

Accreditation Canada

Occupational Safety and Health Administration (OSHA)

Institute for Healthcare Improvement (IHI)

Health Care Management (HCM)

Key Outcomes

1. A culture of patient safety

2. Key stakeholders are engaged

3. Awareness is demonstrated through all communications

4. Performance is measured

5. Staff and patients impacted by medical error are supported

6. Systems/procedures are redesigned to improve reliability and prevent incidents.

7. Complaint Management improves safety, quality, and satisfaction and is

supported

Responsibility We at Brockville General Hospital aspire to be a high performing hospital. As a future high reliability organization, BGH Board and SLT are studying our corporate culture and with our Nursing and Medical leadership will model the necessary risk taking approach to problem solving. Routine culture surveys and adverse event reporting will guide our efforts. Inter unit climate studies, guided by our Quality Committee, will take us to higher levels of reliability and add value to our care. This aspiration will enable the Board and SLT to understand the complexities of Brockville General Hospital care.

P a g e | 6

Steps The next three years (2015 – 2018) the organization will focus, and place resources and energy in the following key improvement initiatives:

Building a Culture of Patient Safety through:

o Staff Orientation, Education, and Continuous Learning

o In house Patient Safety Education Program for Board, SLT, and Medical

and Nursing Leaders

Improving Pharmacy including processes and procedures throughout the

organization pertaining to pharmaceutical care such as:

o Medication Reconciliation at Care Transitions

o Enhanced Electronic Discharge Summaries

o Patient Order Sets

o Pharmatherapeutic Advancements:

Installation of Automatic Drug Dispensers (ADD)

Electronic Medical Administration Record (EMAR)

Computerized Provider Order Entry (CPOE)

Transforming into a Culture of Patient Safety & Organizational Effectiveness

through Lean methodologies and processes

Completion of the MOREOB program

Patient Safety goals are linked to the Strategic Plan, the Quality Improvement Plan, the Operations and Safety Report, daily team huddles, the weekly Leadership Wall Walk, Required Organizational Practices and Professional Best Practice.

Orientation, Education & Continuous Learning

Goal: This comprehensive continuous learning program will create and sustain a culture of patient safety throughout our organization through the integration of professional practice standards, RNAO Best Practice Guidelines, and legislation.

Steps/Action Responsibility Outcomes/Monitoring Timeline

Pre-Hospital Orientation mandatory training available on-line through external website

Inter-professional Educators

Director of People Services

Certificate of completion will be provided to Organization prior to first shift

October 2015 – Ongoing

Mandatory Annual Core Program All Staff, Leadership, SLT, Organizational Development

Director of

Monitoring Data through QHR. It is the responsibility of the Manager to ensure that staff complete

Ongoing

P a g e | 7

People Services

Implement 1 day General Organizational wide Orientation (bi-monthly)



Monitor results through data via QHR to ensure completion by staff

June 2015 – Ongoing

Implement 2 day Clinical Orientation (bi-monthly)



Monitor results through data via QHR to ensure completion by staff

June 2015 – Ongoing

Unit Specific Clinical Orientation (Immediate upon hire)

- Didactic Learning - Buddy Shifts - Independent Learning Curriculum - Unit Specific Mandatory Training


Unit Managers/ Directors


Mandatory Training monitored through data in QHR

Certificate of completion for modules

June 2015 - March 31, 2016

Unit Specific Clinical Orientation Review & Follow-up (3 months, 6 months, 1 year)


Unit Managers/ Directors

Operations Team

SLT

Performance Appraisal with Unit Manager & Interprofessional Educator

Core Curriculum Review with Unit Manager & Interprofessional Educator

June 2015 – March 31, 2016

Unit Specific Support Services & Allied Health Orientation (Immediate upon hire)

Unit Manager/ Director



Sept 2015 – March 2016

P a g e | 8

Unit Specific Support Services & Allied Health Orientation Review & Follow-up (3 months, 6 months, 1 year)

Unit Manager/ Director

Operations Team

SLT



Sept 2015 – March 2016

Corporate Education (Code White, CPR) All Staff, Leadership, SLT, Organizational Development


Required on Day 1 of Corporate Education

Additional sessions offered throughout the year by Organizational Development

Ongoing

Unit Specific Continuing Education (ACLS, NRP, FHS, Triage)

Unit Staff, Leadership, SLT, Organizational Development


In house certified trainers provide this education at least annually.

Ongoing

Leadership Program

2.5 day leadership course will be provided to approximately 30 BGH leaders that will include both informal and formal leaders.

VP & CHRO

Program provided by 3rd party

Certificate of completion

November 2015

Department Specific Education:

Civility in the Workplace

Kangaroo Feeding Pump training

Phlebotomy Training

EKG skills training

Glucometer training – point of care testing

Trillium Gift of Life Network train the trainer sessions plus in-service sessions

Health & Safety Supervisor Training

Injection techniques for medication administration in-services


Department Managers/ Directors

Education provided by Organizational Development, Certified In-house Trainers, or Managers/Directors, as appropriate

Ongoing

P a g e | 9

CADD pump training on new pump

Intravenous therapy for RNs and RPNs

Ebola Education Sessions

Crash cart review

Catheterization education sessions

Computer training on QuadraMed Upgrade

Enhanced PPE training for Highly Infectious Diseases

Infection control for Surgical Services staff

VAC Negative Pressure Wound Therapy education

Central Lines In-services

Code White Training

Handy Audit training

CPR (monthly sessions)

Fire extinguisher training

Palliative Care Education monthly sessions

ASIST training for Mental Health Staff

Mental Status Exam and Restraints for Mental Health staff

Long acting antipsychotic medications in-services

Non-violent Crisis Intervention

PIECES training

WRAP training

Mental Health First Aid

Safe Talk

Gentle Persuasive Approach

P a g e | 10

Pharmacy Improvements Goal: Fully Functioning Modern Pharmacy that meets the needs of today’s care practices and for improved patient safety


Yamazumis completed to identify the work for each role in the area

VP & CNO

Director/ Manager of Pharmacy

Q&IO

Result: Improved work flow for Pharmacists, Technicians, and Assistants.

2015 – ongoing

Practical Problem Solving Event to ensure all medication orders are being reviewed by a pharmacist.

VP & CNO


Q&IO

Medication Order Review Audits are completed to determine effectiveness of medication orders being reviewed by Pharmacist.

Result: Standardized Medication Order

2015 – ongoing

Patient Safety Education Program (PSEP)

Goal: to teach Board, SLT, Medical and Nursing Leaders the language of quality and safety


Create mini lectures for the Board, SLT, Medical and Nursing Leaders from the PSEP modules.

Chief of Staff, Chief Nursing Executive and Quality, Safety, Risk Lead

Result: delivery of lectures to Board, SLT, Nursing and Medical participants.

2015 –2016 18 month cycle. Start Sept, 2015.

Book club mini reviews for interested staff.

COS, CNE and Quality Lead with guest Faculty

A quality book will be reviewed as an open activity for interested staff, learners and community care providers

2015 –this will be a quarterly activity

Learners Safety Journal Club COS, CNE and Quality Lead with guest Faculty

Review of latest select publications

Oct, 2015-

P a g e | 11

Review Process

Installation of ADDs

Pharmacists / IMIT

Q&IO

Improved medication administration, drug tracking, and drug accessibility/availability

November 2015

Completion of CPOE & EMAR

Pharmacists

Dr. Beveridge


Implementation of CPOE and EMAR is part of a 3 year strategy

August 2015 – ongoing

Medication Reconciliation Director/ Manager of Pharmacy

Dr. Beveridge

Clinical Managers/ Directors

Pharmacy Technicians, Nurses and Physicians

Medication Reconciliation at Admission – 75% compliance (QIP)

QuadraMed 5.4 to 6.0.1 upgrade for medication reconciliation at care transitions

October 2014 – ongoing

Electronic Discharge Summaries

An electronic Discharge Summary Tool that will administratively document the patient’s discharge and provide patient discharge instructions.

Manager of Health Records

Senior Systems Analyst

Chief of Staff



Pharmacy Technicians, Nurses and Physicians

Need to understand first how KGH developed this tool

Jan – Mar, 2016

P a g e | 12

Patient Order Sets

We have developed Order Sets for: Febrile Neutropenia Pneumonia Arthoplasty Total Hip/Knee Post Op Community Acquired Pneumonia


Dr Beveridge


Promote best practice guidelines and evidence-based outcomes, such as length of stay, post op infections, wait time for rehab, and readmissions

Upgrade of Policies and Procedures as per Pharmacy Inspection completed in June 2015.

Specifically: Leave of Absence Medication Nurse Dispensing


Identified pharmacy policies reviewed and revised (if applicable), rolled out to staff, and posted on SharePoint.

June 2015 – ongoing

Transformation & Lean

Goal: Foster a culture of Continuous Improvement focusing on Safety, Quality, Cost, Delivery and Risk


Every process improvement & project will be put through a number of steps to ensure that patient safety and quality are at the heart of what we do at Brockville General Hospital.

President & CEO

VP & Chief Nursing Officer

Chief of Staff

Transformation & Process Improvement Specialist

Project Management Specialist

Quality & Risk Specialist

Regular auditing is performed for compliance and reported with follow-up action taken as required.

Reports to Board of Governors monthly

Reports to Senior Team, Operations Team and Leadership Team weekly

Outcomes

ED Skills Matrix developed to identify current/future learning needs and clarify champions

Surgical Specimen delivery to pathology reduced by 50 minutes

Patient wait time for endoscopy reduced by

May 2014 – Ongoing

P a g e | 13

1.5 hours

Verification of patient information of >20,000 patients

Develop a Quality & Improvement Team to facilitate and support the process

President & CEO

Process Improvements throughout the organization

May 2015 – Ongoing

Re-vamp Huddle Boards throughout the Organization

Senior Leadership Team

Monthly Gembas will monitor the outcomes

Sept 2015 – ongoing

Develop a Leadership Weekly Meeting to review improvements/projects

Quality & Improvement Team

Weekly Wall Walks September 2015 - ongoing

Develop a Quality & Improvement Office Governance Structure

Quality & Improvement Team

Structure will ensure the right projects are done the right way

Complete

Develop a path for implementation of process improvements and projects

Quality & Improvement Office

Ensures roles & responsibilities with sign-off of steps

Complete

Develop a Project Qualification and Prioritization Matrix which focuses on Safety, Quality, Cost, Delivery & Risk

Quality & Improvement Office

Projects & Initiatives are measured for impact to safety, quality, cost and delivery

Complete

Develop a process for project management

Project Management Specialist

Update of PODs Sept 2015 – Ongoing

Develop a process for process improvements

Transformation & Process Improvement Specialist

Update of PPS Sept 2015 – Ongoing

Create Ideas to Actions Team to review staff and physician improvement ideas

CEO Buy-in and involvement from staff across the organization

Sept 2015 – Ongoing

Clarify Roles & Responsibilities for Improvement Work

Senior Team Smooth flow from PODs to PPS’

Sept 2015 – Dec 2015

Leadership Coaching and Re-training Quality & Improvement Office

Check in and re-training based on needs from the introduction of Lean in 2014. Improved

Sept – Dec 2015

P a g e | 14

Additional Programs being Monitored and Evaluated Daily Team Huddles

Senior Leadership Gemba

understanding and certificate of completion will be provided

MOREOB

Goal: To complete the MOREOB program. The objective of the MOREOB program is to manage obstetrical risk efficiently. This comprehensive improvement program will create a culture of patient safety on our obstetrical unit through the integration of professional practice standards, guidelines and safety concepts.


Module 3 training

MOREOB Program/Manager

OBS Unit/OBS Staff

Module 3 training will commence for the core team & nursing staff

Sept 2015

MOREOB Certification MOREOB Program/Manager

OBS Unit/OBS Staff

The OBS unit will receive MOREOB certification

February 2016

Review further MOREOB Certification OBS Manager / Director / SLT

Review further education and plan for continuous learning

February 2016

2015-18 patient safety plan - brockville general hospital · patient safety education program...

Documents